Why is a Young Man Suddenly Convinced He's a Doctor?

When an economics student starts practicing medicine on his classmates, real doctors have to step in.

When Alvin arrived at the hospital, he believed he’d been sent there as a
doctor working on behalf of the U.S. government. “Which patient do I need
to see first?” he asked the triage nurse.

Until recently, Alvin had been an ordinary economics graduate student. But
somehow he’d become convinced that he was a trailblazing physician who
needed to identify a rare strain of tuberculosis before it spread
throughout campus.

That morning, he arrived at his graduate school classroom with a
stethoscope around his neck, a surgical mask over his face and a bag
containing more masks and several thermometers. He began to practice
medicine on his classmates.

At first, his manner and physician attire made them think he was joking, as
Halloween was just around the corner. But when he tried to remove the shirt
of a female student to better listen to her lungs, their late-arriving
professor called the police. And the police called an ambulance.

What caused this previously healthy 25-year-old man to become delusional?
After an initial screening from the emergency medicine physician on duty, I
was called to sort this out.

At the time, I was a new psychiatry resident. But even at that early part
of my career, I knew to focus on four possibilities for Alvin’s behavior: a
stress reaction from a trauma, a manic phase, a psychotic episode or a
drug-induced state. I’d also heard about medical conditions, such as lupus
and hyperthyroidism, that could cause severe psychological changes. But the
emergency room doctor found no supporting evidence for those possibilities
after his examination.

Skimming Alvin’s medical records, I learned that he had visited the student
health clinic the year before. He was diagnosed with depression but
declined treatment. The note also mentioned occasional marijuana use, but
not in more than a year. He told the doctors he hadn’t used any other
street drugs. In terms of his physical health, the records showed he’d
recently visited the health clinic for cold symptoms and received a
prescription decongestant.

Essentially, I was starting from scratch.

Dialed to 11

I met Alvin in a small room in the emergency department’s psychiatric wing.
He paced in a circle and was doing some sort of counting exercise with his
fingers. He seemed a few days overdue for a shave and a shower.

I smiled and gently told Alvin that his classmates and teachers had
concerns about his mental state, as did the nurses and doctors at the
hospital. He nodded. I asked him why he thought they were worried.

“Because I have been energetic,” he answered. “Maybe too much so for them.”

“How long have you been feeling this way?” I asked.

“A few days. Maybe a week. Conventional time isn’t as important for me
now.”

He told me that he hadn’t slept more than two or three hours a night. And
even that felt like too much because he had so much lifesaving work to do.
He said he hadn’t had any recent traumatic experiences in his life or with
anyone close to him.

It sounded like textbook mania. But from what?

The X Factor

Alvin’s lab results came back. Stepping away to a nearby computer station,
I saw that his alcohol level was zero. Also, his urine drug screen — which
tested for marijuana, cocaine, phencyclidine (PCP), opioids,
benzodiazepines and amphetamines — came back clean. It appeared that drugs
weren’t causing his state.

His blood tests showed normal liver, kidney, glucose and
electrolyte/mineral values. We still needed to wait for results on his
thyroid levels, but I suspected the data would not show an identifiable
cause for his behavior. He seemed headed toward a diagnosis of bipolar
disorder and treatment through medications.

I went back to Alvin’s room to perform a physical exam. Before beginning, I
asked him how his physical health had been in recent months. He told me he
had a bad cold five or six weeks ago and missed a few days of classes. He
saw a doctor who wrote him a prescription, but the medicine didn’t help his
condition.

Alvin said he began to improve only after taking an over-the-counter
medicine. Out of curiosity, I asked him its name.

“DXM,” he said.

I stared blankly. “Dextromethorphan,” he continued. “It’s the active
ingredient in most cough suppressants. I started with the pills. I switched
over to the liquid a few weeks ago.”

David Vogin

Switched over a few weeks ago? The instructions on cold medicines always
say to stop use after a week, or at most 10 days. “How long did you end up
taking it?” I said.

“I’m still using it,” he said, reading the confusion on my face. “For
recreational purposes.”

I frowned in surprise. I’d always been naïve and cautious about drugs in my
personal life. And while I’d seen TV reports on the decongestant
pseudoephedrine being used to produce crystal methamphetamine, I hadn’t
heard anything similar about dextromethorphan to make me view it as a drug
that could be abused. Nor had I heard about this in medical school.

My off-handed question about the medicine’s name opened a new path of
investigation. Could this drug explain his behavior?

Lessons Learned

After looking into DXM’s history, I found that it was approved by the FDA
in 1958 as a non-prescription cough suppressant. During the 1990s, a
handful of obscure medical case reports described the potential dangers of
DXM when taken in high doses. It could produce psychological symptoms of
intense euphoria and altered perceptions of surroundings, similar to what
people experience with the drugs ketamine and PCP.

As with those drugs, using DXM causes a pleasurable high at first, but it
can subsequently lead the user into a psychotic state. For example, in
1996, a medical journal reported the case of a lawyer standing half-naked
outside his home and wielding a gun in an effort to free his wife; he
believed she was being held hostage inside. He had been using increasing
amounts of cough syrup with DXM for three months.

In 2005, a few years after my encounter with Alvin, the FDA published a
warning on the dangers of taking DXM in high doses. Today, the drug is
still part of over 100 cough and cold medicines. In recommended amounts,
it’s safe. But the potential for abuse is always there.

Alvin acknowledged that DXM had clouded his thinking, and he agreed to be
admitted to the inpatient psychiatric hospital floor for observation. Once
he stopped taking the drug, he returned to his normal state within three
days. He said during his discharge that what had started out as fun had
gotten out of hand, and that he’d learned his lesson.

Alvin’s case was an eye-opener for me early in my career. Realizing that
both I and the emergency room doctors had almost overlooked this less
well-known type of drug abuse, I learned two important lessons: ask
patients extra questions and be humble enough to let them lead you to their
diagnoses.

[This article originally appeared in print as "Delusions of Grandeur"]